Drug plan still creating confusion at pharmacies

June 11, 2006|By NEW YORK TIMES NEWS SERVICE

McALLEN, Texas -- In Washington, Bush administration officials say Medicare's new prescription drug program is humming along smoothly, filling more than 3 million prescriptions a day and cutting costs by an average of 50 percent for each beneficiary.

But here in the Rio Grande Valley, the picture is different.

Many patients say they have difficulty getting the drugs they need. Pharmacists, swamped with questions and complaints from beneficiaries, have run into many practical problems as they try to navigate a complex program administered by dozens of prescription drug plans, each with its own policies and procedures. Doctors and pharmacists are struggling to figure out which drugs are covered by which plans.

"Intellectually, the program is a good idea," said Dr. E. Linda Villarreal, a former president of the Hidalgo-Starr County Medical Society. "But there's been total chaos and confusion among most of my patients, who do not understand the system and how to work it."

Jose M. Flores, 66, a Medicare beneficiary who lives outside McAllen, used the new drug benefit four times from January to April to purchase Byetta, an injectable medicine for diabetes. Each time he paid $40.

So when he went to the pharmacy May 25, he was dismayed to be told that he owed $167.56 for the next month's supply. Flores had reached the gap in Medicare's drug coverage. He had to pay the full price of Byetta. His Medicare drug plan paid nothing.

In coming months, millions of beneficiaries will have similar experiences, as the cost of their drugs reaches the initial coverage limit of $2,250. Like Flores, they will have to pay the full cost of each medicine until their out-of-pocket costs reach $3,600. At that point, Medicare coverage resumes, paying 95 percent of the cost of each prescription.

Texas has 47 Medicare drug plans, with different premiums, co-payments and lists of covered drugs, known as formularies.

Gilbert Tovar, who runs Lindberg Pharmacy in McAllen, said he had expected the problems to end after May 15, the deadline for people to enroll. But, he said, "the logistical nightmare continues because dual-eligible beneficiaries - those eligible for both Medicare and Medicaid - can switch plans every month."

Competition among Medicare drug plans drove down premiums but has complicated operation of the program. Pharmacists here say that most of their low-income customers have insurance cards from several Medicare drug plans.

"They come in and ask, `Which card should I use?'" said John P. Calvillo, a pharmacist in Edinburg, Texas, outside McAllen.

"Doctors and pharmacists often have trouble finding out what drugs are on the formularies," he said. "It's a crapshoot every day."

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